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Interview: Gwen Adshead, forensic psychiatrist and psychotherapist

05 March 2021

‘Making prisons horrible, frightening places could make risky people even more risky’

I trained first as a doctor, then as a psychiatrist, and then as a psychotherapist. “Forensic” just means related to law: I work with people who’ve got into trouble with the law because of their mental-health problems. I also work in courts, providing expert testimony to assist in their deliberations: I mainly do family court work, and not much crime any more.

I found general psychiatry challenging, because it seemed to involve judgements about normality and difference, and diagnoses which patients didn’t always like or accept. I trained as a psychotherapist so I could spend more time talking to patients. I’m a group analyst, but I’m also interested in attachment theory, mindfulness-based cognitive therapy, and mentalisation-based therapy.

I completed a Master’s in medical ethics and law at King’s [London], and got interested in how law approaches complex human dilemmas. Forensic psychotherapy brought these interests together.

I started work at Broadmoor in richer, more generous times, when a psychotherapy department was being developed.

I think evil is a state of mind that we can all get into — better as an adjective, not a noun. When we say something or someone is evil, we’re doing something performative. (I know that’s not the proper linguistic sense of “performative”.) People rarely refer to themselves as evil; rather, it’s a judgement made by others, performing a task for the whole community, which may be why it comes up so much in judges’ sentencing remarks, and the tabloids.

“Evil” implies a person’s no longer a person — someone who’s lost their humanity in the sense of that which connects us to others. I’ve rarely met such a person in prison or my hospital. I do meet people regularly who’ve very little sense of others as “real”, and who struggle with honesty and authenticity, but only a few of them are in Broadmoor or prison. I’ve met some people who seem to have lost their humanity, but they’re rare; and, even then, they can still be not evil in some circumstances.

I start from Kant’s premise that we live and breathe in a moral universe. I’ve never met a real amoralistic nihilist, although there are a few people who claim to be. The people I meet see themselves as belonging to a moral universe and having a moral identity, which they usually admit to messing up in some way. They often want a chance to make good, and do or be someone different.

I take justice very seriously. I don’t believe in retribution, but I believe in inviting offenders to make good and repair both wrong and harm if they can. In that sense, a justly applied punishment can be redemptive, if it offers a chance to make good. Many prisoners feel it’s just for them to do time for their offence, and conversely are furious when they are unjustly (in their view) either convicted or sentenced.

Doing justly, having compassion, and walking humbly — that’s the job for me and the people I meet. We’re all in the same boat. I’ve written a book exploring this, called The Devil You Know, with my friend Eileen Horne.

Making prisons horrible, frightening places, where people are made to feel small and ashamed, is counter-productive, and could make risky people even more risky. Grown-up politicians need to gently advise the citizenry that, although revenge is a natural human feeling, it’s one we have to manage, like other difficult feelings. We have the right to deprive people of liberty to prevent them from harming others, but not the right to treat them badly. Government has a duty to encourage the citizenry to be grown-up.

So prisons should be places where there are greater resources for therapy and psychosocial learning. There is so much more that we could do, learning from places like Norway and developing alternatives to custody. A year in prison can cost £40,000, which might be spent in better ways.

Not all violence-perpetrators are the same. A 21-year-old man who kills another in a drug-related argument has nothing in common — beyond a conviction for murder — with a 56-year-old man who strangles his wife in an argument. We must ensure all such people get a really good formulation of their violence, which sets out in depth how the violence occurred, what it meant to the perpetrator before, during, and since the event; and how they see their risk to others and what they plan to do about it. Some violence-perpetrators can be rehabilitated, but some may never leave prison because they cannot see their cruelty and take responsibility for it.

Changing your mind for the better is a dynamic process. No one should be abandoned, and prisoners do get regular reviews of their risk to see if they’ve had a change of heart or mind, which is as it should be.

Revenge cannot be an excuse for cruelty. But adverse childhood experiences can be introduced in mitigation at sentencing, and sometimes that childhood trauma may lead to mental disorders which may be so bad that they diminish responsibility in homicide cases. A lot of cruelty arises from despair.

It’s a technical error to let personal experience distract me, or to talk about myself to patients, but yes — I do think about my shortcomings, and regularly acknowledge to myself that my patients and I are more alike than different.

Mindfulness practice really opened up something for me about how minds work, and how my mind might work better. The compassion practices made me aware of how much hostility to self and others I carried, and was still carrying. The training enabled me to be a better therapist.

I didn’t learn to pray until I started meditating regularly; so I’m grateful for this beyond measure.

Prisons are hard places to learn to meditate in — although some people manage it; and many patients are too unwell or have too much pain to learn. It’s been easier teaching staff, and I run a mindfulness retreat for doctors every year with two other doctors, one a minister and one a monk.

From the age of five, I went to an Anglican cathedral: BCP, Stanford in C, etc. So I assumed that God was in the cathedral, and I was happy to meet him there. I felt scared, but also reassured by God as a presence. I knew Jesus only from Bible stories, and he seemed a remote paragon of virtue to whom I felt little connection. I learned about the Holy Spirit similarly, but it was all linked up with being a good person who did good things, like going to church.

It took a personal tragedy to wake me up from spiritual torpor, or dissociation, and open me up to a new way of relating to the mystery of the divine in the present moment, which is both the journey and the journey’s end.

I’d like to live a life of holiness every day. Or maybe just one day! To be Christ’s eyes and hands and feet and heart for others, and not get distracted by my own pettiness. I’d also like to write a really good detective story, and grow a really good show of sweet peas.

Stupidity of every kind, makes me angry, especially my own. The wilful misuse of God-given intelligence in order to be cruel or win some imaginary game. Misusing the gospel to torment others: that makes me angry.

The sound of my children’s voices, lifted in laughter or song, makes me happy, as does singing in harmony with others. I miss that so much at present.

Hope is a duty as well as a virtue to be practised, and a way of relating to the world; so I try to practise hope in ways that are tempered with a practical appreciation of how bad things can be. History tells us that hopeful people can bring about change and stand for virtue. In matters spiritual, we’ve been promised that we shall see face to face and be known in full; so that’s my hope.

I was introduced to a three-by-five routine: recalling five ways in which I didn’t do God’s will today; five ways God’s goodness was present in my life today that I’m thankful for; and five people or groups who need my prayers today. I also pray for people I’m currently most cross with, and I pray for God’s help in letting go those pesky deadly sins.

I’d like to have a few hours with Richard Rohr, whose work has been so helpful to me, and whose generosity of love is palpable. Or Jack [C. S.] Lewis. So much to ask, so much to argue about, so much to be thankful for. The Screwtape Letters are still one of my top reads.


The Devil you Know by Gwen Adshead and Eileen Horne will be published by Faber in June at £12.99 (Church Times Bookshop £11.69) and can be pre-ordered.

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